FECALYSIS

Verian John Hoo – Sudario

College of Medical Technology
• The GI tract is a series of hollow organs
joined in a long, twisting tube from the
mouth to the anus.

• The hollow organs that make up the GI

tract are the mouth,
esophagus, stomach, small intestine,
large intestine, and anus. The liver,
pancreas, and gallbladder are the solid
organs of the digestive system
 FECAL SPECIMEN
• bacteria, cellulose
• undigested foodstuffs
• GI secretions
• bile pigments
• cells from the intestinal walls
• electrolytes
• water
• 100 to 200 g of feces is excreted in a 24-hour period
• Bacterial metabolism produces the strong odor associated
with feces and intestinal gas (flatus).
 diarrhea
• increase in daily stool weight above 200 g, increased liquidity
of stools, and frequency of more than three times per day

CLASSIFICATION
• illness duration
• mechanism
• severity
• stool characteristics
ACUTE:
• Diarrhea less than 4 weeks
• Secretory
• Osmotic
Chronic: • Intestinal hypermotility.
• Diarrhea greater than 4 weeks
 LABORATORY
• FECAL ELECTROLYTES
– NORMAL:
Fecal Na: 30 mmol/L
Fecal K: is 75 mmol/L
• FECAL OSMOLALITY
normal total fecal osmolarity is close to the serum osmolality
(290 mOsm/kg)
• stool Ph
• Osmotic gap = 290 – [2 (fecal sodium + fecal potassium)]
 Secretory Diarrhea

• increased secretion of water.

• Bacterial, viral, and protozoan infections produce increased secretion of water
and electrolytes, which override the reabsorptive ability of the large intestine,
leading to secretory diarrhea
– Escherichia coli
– Clostridium
– Vibrio cholerae,
– Salmonella
– Shigella,
– Staphylococcus
– Campylobacter
– protozoa
– Cryptosporidium
• drugs
• stimulant laxatives
• hormones
• inflammatory bowel disease (Crohn disease, ulcerative colitis,
lymphocytic colitis, diverticulitis
• endocrine disorders (hyperthyroidism, Zollinger-Ellison syndrome,
VIPoma)
• neoplasms
• collagen vascular disease
 Osmotic Diarrhea
• caused by poor absorption that exerts osmotic pressure
across the intestinal mucosa

• Maldigestion (impaired food digestion)

• Malabsorption (impaired nutrient absorption by the
intestine)
 CAUSES
• disaccharidase deficiency (lactose intolerance)
• malabsorption (celiac sprue)
• poorly absorbed sugars (lactose, sorbitol, mannitol)
• Laxatives
• magnesium-containing antacids
• amebiasis
• antibiotic administration
 irritable bowel syndrome (IBS)
• functional disorder in which the nerves and muscles of the
bowel are extra sensitive,
• causing cramping, bloating, flatus, diarrhea, and constipation.

• IBS can be triggered by food, chemicals, emotional stress, and

exercise.
 ALTERED MOTILITY
• enhanced motility (hypermotility)
• slow motility (constipation)
 Intestinal hypermotility
• excessive movement of intestinal contents through the GI
tract that can cause diarrhea because normal absorption of
intestinal contents and nutrients cannot occur.

• enteritis, the use of parasympathetic drugs, or with

complications of malabsorption
. Rapid gastric emptying (RGE) dumping syndrome
• hypermotility of the stomach and the shortened gastric
emptying half-time, which causes the small intestine to fill too
quickly with undigested food from the stomach.
• A gastric emptying time of less than 35
• can be caused by disturbances in the gastric reservoir or in the
transporting function.

• Early dumping & Late dumping

  10 to 30 minutes following meal ingestion.
Early dumping
Symptoms :  2 to 3 hours after a meal
• nausea
• vomiting
• bloating SYMPTOMS:
• Cramping Weakness
• diarrhea sweating
• dizziness dizziness
• fatigue
 Steatorrhea

• diagnosing pancreatic insufficiency and

small-bowel disorders that cause
malabsorption.
• Absence of bile salts that assist
pancreatic lipase in the breakdown and
subsequent reabsorption of dietary fat
(primarily triglycerides) produces an
increase in stool fat (steatorrhea) that
exceeds 6 g per day
• cystic fibrosis, chronic pancreatitis, and carcinoma,

• present in both maldigestion and malabsorption conditions and

can be distinguished by the D-xylose test.

• D XYLOSE TEST:
 s a medical test performed to diagnose conditions that present
with malabsorption of the proximal small intestine due to defects
in the integrity of the gastrointestinal mucosa

 Urine D xylose low: malabsorption

 Dxylose normal: Pancreatitis
Specimen
collection
Macroscopic
Screening
Blood that originates from the esophagus, stomach, or
duodenum
 takes approximately 3 days to appear in the stool; during this
time,
degradation of hemoglobin produces the characteristic black,
tarry stool
Blood from the lower GI tract
requires less time to appear and retains its original red color.
Black stool
• ingestion of iron, charcoal or bismuth, and some medications and some
Red stool
foods, including beets

Green stools
 oral antibiotics, because of the oxidation of fecal bilirubin to biliverdin.
 Ingestion of increased amounts of green vegetables
 food coloring
 Microscopic
Examination of
Feces
 Fecal Leukocytes
• Leukocytes, primarily neutrophils, are seen in the feces in
conditions that affect the intestinal mucosa, such as ulcerative
colitis and bacterial dysentery
• Methylene blue, Grams stain & Wright stain
• three neutrophils per high-power field can be indicative of an
invasive condition

• A lactoferrin latex agglutination test

 The presence of lactoferrin, a component of granulocyte
secondary granules, indicates an invasive bacterial pathogen.
 Muscle Fibers
• can be helpful in diagnosing and monitoring patients with
pancreatic insufficiency

• also be seen in biliary obstruction and gastrocolic fistulas.

 Qualitative Fecal Fats
• monitor patients undergoing treatment for malabsorption
disorders
• neutral fats (triglycerides), fatty acid salts (soaps), fatty acids,
and cholesterol
• dyes Sudan III, Sudan IV, or oil red O; Sudan III
• Soaps and fatty acids do not
stain directly with Sudan III
• second slide must be
examined after the
specimen has been mixed
with acetic acid and heated
• Normal : 100 small droplets, less than 4 µm in diameter/hpf

• Steatorrhea
 100 small droplets1-8 µm in diameter/hpf
 100 droplets measuring 6 to 75 µm is increased

MALABSORPTION
 An increased amount of total fat on the second slide with normal fat
content on the first slide
MALDIGESTION
 Increased neutral fat on the first slide
Chemical Testing
of Feces
 OCCULT BLOOD

• Guaiac-Based Fecal Occult

Blood Tests

• Immunochemical Fecal
Occult Blood Test
 Guaiac-Based Fecal Occult Blood Tests

• detecting the pseudoperoxidase activity of hemoglobin.

Note: pseudoperoxidase activity is present from hemoglobin

and myoglobin in ingested meat and fish, certain vegetables and
fruits, and some intestinal bacteria.
Two samples from three different stools should be tested before a negative
result is confirmed

Guaiac-Based Fecal Occult Blood Tests Immunochemical Fecal Occult Blood Test
 interferences
Patients should be instructed to avoid:
• eating red meats, horseradish, melons, raw broccoli,
cauliflower, radishes, and turnips for 3 days before specimen
collection.
• Aspirin and NSAIDs other than acetaminophen should not be
taken for 7 days before specimen collection.
• Vitamin C and iron supplements containing vitamin C should
be avoided for 3 days before collections
 Immunochemical Fecal Occult Blood Test
• specific for the globin portion of human hemoglobin and uses
polyclonal anti-human hemoglobin antibodies.
• more sensitive to lower GI bleeding that could be an indicator
of colon cancer or other GI disease and can be used for
patients who are taking aspirin and other anti-inflammatory
medications
• do not detect bleeding from other sources
 Porphyrin-Based Fecal Occult Blood Test
• measures both intact hemoglobin and the hemoglobin that has
been converted to porphyrins.

• more sensitive to upper GI bleeding

• avoid red meat for 3 days before the test.

Quantitative Fecal Fat
Testing
 INSTRUCTIONS:
• maintain a regulated intake of fat (100 g/d) before and during
the collection period.
• collected in a large, preweighed container.

• Before analysis, the specimen is weighed and homogenized.

• PRESERVATION: Refrigeration
 Van de Kamer titration
• , fecal lipids are converted to fatty acids and titrated to a
neutral endpoint with sodium hydroxide.

• Approximately 80% of the total fat content is measured by

titration
• gold standard for fecal fat,
hydrogen nuclear magnetic resonance spectroscopy

• (1H NMR) method

• homogenized specimen is microwaved-dried and analyzed.

Reporting:
• grams of fat
• the coefficient of fat retention per 24 hours.

Reference values based on a 100 g/d intake are 1 to 6 g/d or a

coefficient of fat retention of at least 95%.
 acid steatocrit
• rapid test to estimate the amount of fat excretion.
• It is similar to the microhematocrit test
• more convenient than a 72-hour stool collection.
• reliable tool to monitor a patient’s response to therapy and
screen for steatorrhea in pediatric populations
 Near-infrared reflectance spectroscopy

• procedure for fecal fat that requires

less stool handling

• 48- to 72-hour stool collection to

exclude day-to-day variability, but it
does not require reagents after
homogenization of the sample
• measurement and computed processing of signal data from
reflectance of fecal surface, which is scanned with infrared
light between 1400 nM and 2600 nM wavelength.
APT Test (Fetal Hemoglobin)
• fetal hemoglobin, the
solution remains pink (HbF)

• denaturation of the
maternal hemoglobin
(HbA) produces a yellow-
brown supernatant after
standing for 2 minutes
 Fecal Enzymes
• Decreased production of these enzymes (pancreatic
insufficiency
• associated with disorders such as chronic pancreatitis and
cystic fibrosis.
• Steatorrhea occurs, and undigested food appears in the feces

• trypsin, chymotrypsin, and elastase I.

 Fecal chymotrypsin
• more resistant to intestinal degradation
• more sensitive indicator of less severe cases of pancreatic

• is capable of gelatin hydrolysis but is most frequently

measured by spectrophotometric methods. insufficiency.
 Elastase I
• isoenzyme of the enzyme elastase and is the enzyme form
produced by the pancreas

• Fecal elastase I is pancreas specific and its concentration is

about five times higher than in pancreatic juice.

• can be measured by immunoassay (elisa kit)

 carbohydrates
• may be present as a result of intestinal inability to reabsorb
carbohydrates, as is seen in celiac disease,

• lack of digestive enzymes such as lactase resulting in lactose

intolerance.

• substances detects congenital disaccharidase deficiencies as

well as enzyme deficiencies due to nonspecific mucosal injury
 Clinitest
• distinguish between diarrhea caused by abnormal excretion of
reducing sugars and those caused by various viruses and
parasites

• general test for the presence of reducing substances

• positive result would be followed by more specific serum
carbohydrate tolerance tests, the most common being the D-
xylose test for malabsorption and the lactose tolerance test
for maldigestion.
END